Neurosurgery Coding Alert

Here's what -modifier 51 exempt- really means for your bottom line

Anytime you report an -add-on- procedure code, you must also be sure to report an approved, primary procedure code on the same claim. To better illustrate the consequences of add-on status, we-ll use the example of spinal bone graft codes--and add-on codes--20930-20938. Add-On Can't Stand Alone You should never report an add-on code alone. By definition, an add-on code describes an -additional- service that occurs only at the same time as another, more extensive procedure, says Suzan Berman-Hvizdash, CPC, CPC-E/M, CPC-EDS, physician educator for the department of surgery at the University of Pittsburgh Medical Center. Generally, CPT will include an editorial note, following the add-on code's descriptor, to instruct you as to which primary procedure codes should precede that add-on code.

Example: For all spinal bone graft procedures 20930-20938, the appropriate, approved primary procedures are 22319 (fracture treatment) and 22532-22533, 22548-22558, 22590-22612, 22630 and 22800-22812 (arthrodesis/spinal fusion). You can find these instructions immediately following each of the code descriptors for 20930-20938.

You may occasionally report more than one type of add-on code during the same operative session.

For instance, in addition to arthrodesis, spinal bone grafts also frequently occur during the same session as spinal instrumentation procedures (22840-22855). The spinal instrumentation procedures are themselves represented with add-on codes, and you may report them in addition to any spinal bone grafts and arthrodesis.

CPT supports this coding with instructions preceding both the arthrodesis and spinal instrumentation codes advising, -To report bone graft procedures, see 20930-20938. (Report in addition to code[s] for definitive procedure[s].)- And although the national Correct Coding Initiative (CCI) bundles various bone grafts into many orthopedic procedures, such bundles do not apply to spinal bone grafts with arthrodesis (22548-22812) and/or spinal instrumentation (22840-22855) procedures.

Avoid Modifier 51, or Pay the Price You should never append modifier 51 (Multiple procedures) to a designated add-on code.

Modifier 51 designates a procedure or service that is usually performed independently but, in the cited case, is performed at the same time as another procedure. Because add-on codes are already defined as additional services or procedures, modifier 51 is redundant and, for some payers, can even harm your reimbursement, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, manager of compliance education at the University of Washington Physicians.

CPT stresses this point by stating, -All add-on codes found in the CPT book are exempt from the multiple procedure concept.- That is, the payment value assigned to these codes reflects their status as -additional procedures,- and therefore any further reduction in reimbursement is unwarranted and unjustified.

CPT 2008 Changes: An Insider's View goes even further, stating, -As modifier 51 exempt codes are typically adjunctive or reported with other procedures, the amount of pre- [...]